LIFESTYLE ASSESSMENT - Naturopathic …...33 The Bridle Trail, Unit 3 Telephone: 905-940-2727...

33 The Bridle Trail, Unit 3 Telephone: 905-940-2727 www.naturopathicfoundations.ca Markham, Ontario L3R 4E7 Fax: 905-940-2721 blog.naturopathicfoundations.ca

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LIFESTYLE ASSESSMENT The Lifestyle Assessment Questionnaire is designed to provide insight into your personal health. When embarking on a personal health plan, it is important for you and your practitioner to have a benchmark of where you are, your personal and family history, and what your behaviours, concerns, and thoughts are with regards to your health. The following Lifestyle Assessment Questionnaire is not designed to give a medical diagnosis. It identifies your current strengths, risk factors that might be present, and it highlights key areas of concern. It also assists in uncovering the factors that may be contributing to your symptoms or current concerns. This questionnaire will take about 1 - 2 hours to complete. The time that it takes to answer the questions is completely up to you and has no bearing on the results. General Guidelines to Follow when filling out the Lifestyle Assessment:

Use the last three months as a guide to current symptoms when answering the questions.

If you feel that something that pertains to you is missing in any section feel free to add it.

The Lifestyle Assessment is broken down into eight categories: A. GENERAL INFORMATION

B. EXTERNAL FACTORS

C. FAMILY MEDICAL HISTORY

D. MEDICATIONS, SUPPLEMENTS & OTHER TREATMENTS

E. EXERCISE

F. PAST & PRESENT HEALTH CONCERNS

G. REVIEW OF PHYSICAL SYSTEMS

H. GENERAL INFORMATION ON DIET

I. PERSONAL VALUES

J. STRESS

K. HEALTH POSITIONING STATEMENTS

A. GENERAL INFORMATION

Name: Today’s date:

Date of birth: Occupation:

Number in household: Relationship to you?

Number of pets: What kind of pets?


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A TYPICAL DAY

List the amount of time you spend doing the following activities during a typical day Note: The total time will probably add up to more than 24 hours due to the nature of the question.

Hours Activity Hours Activity

Sleeping Exercising

Personal Hygiene Relaxing or meditating

Driving a vehicle Reading

Taking public transport or passenger Listening to music

Working Watching television

Computer related work Being outside

House or yard work Time alone

SATISFACTION LEVEL ON DIFFERENT ASPECTS OF YOUR LIFE

Using the scale provided identify your level of satisfaction with respect to the categories listed. Scale: 1 - not comfortable at all with current situation 2 - low level of comfort with current situation 3 - okay most of the time with current situation 4 - fairly comfortable with current situation 5 - high level of comfort with the current situation

Category Satisfaction or Comfort Level

with the Situation

Changed in

Last 3 Months

Changed in

Last Year

DIET 1 2 3 4 5 YES NO YES NO

EXERCISE 1 2 3 4 5 YES NO YES NO

WELLNESS 1 2 3 4 5 YES NO YES NO

LIFESTYLE 1 2 3 4 5 YES NO YES NO

ENVIRONMENT 1 2 3 4 5 YES NO YES NO

WORK 1 2 3 4 5 YES NO YES NO

FAMILY 1 2 3 4 5 YES NO YES NO

RELATIONSHIPS 1 2 3 4 5 YES NO YES NO


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B. EXTERNAL FACTORS

The following section identifies external and environmental factors that may be affecting your health. Please check the box that is the most appropriate, or fill in the blanks as indicated.

ENVIRONMENT

Where did you grow up? _______________________________________________________________________

Where do you live? city suburbs country farm

Type of home? apartment/condo semi/townhouse detached house

Do you live near hydro towers? YES NO In the past Number of years? _________

Do you live near a factory? YES NO In the past Number of years? _________

Please list any chemicals, toxins, or other factors in your environment that might be affecting your health:

______________________________________________________________________________

PERSONAL

What are your hobbies? ____________________________________________________________

How much time do you spend in nature? _________________________________________________________

Do you smoke? YES NO In the past How many packs a day? ____________

Does anyone in your family smoke? YES NO In the past

Do you use natural personal care products? YES NO If so, what brand? ___________________

Do you pay attention to the chemicals in personal care products? YES NO

Do you use sunscreen? YES NO If so, what brand? _____________________________________

Do you dye your hair? YES NO If so, what type? _____________ How often? ____________

Do you have any body piercings? YES NO If so, where? _________________________________

Do you have any permanent tattoos? YES NO

Have you had any cosmetic surgery? YES NO If so, when? _______________________________

What type of cosmetic surgery? _________________________________________________________________

How many hours a day do you spend watching television? ____________ On a computer? ____________

Do you use wireless networks at home? at work? If so, how many hours daily? ____________

What type of phones do you use? cord cordless cellular

How many hours a day are you on a cell-phone or PDA? ____________

Do you wear an ear piece for your phone? YES NO If so, how many hours daily? ___________


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What types of Bluetooth devices do you use? _____________________________________________________

How many trips on an airplane do you take a year? ____________

HOUSEHOLD

Type of house you grew up in? __________________________________________________________________

Number of times you have moved homes? ____________ How old is your current home? ____________

Have there been any recent home renovations? YES NO If so, what type? __________________

Is there a history of flooding in your home? YES NO In the past

Do you use natural cleaning products? YES NO If so, what brand/type? ___________________

What type of cooking utensils (pots and pans) do you use? _________________________________________

What type of storage containers do you use? ______________________________________________________

What type of container do you use to carry your drinking water? ____________________________________

WORK

Do you enjoy your work? YES NO Why? __________________________________________

Describe your work load: ______________________________________________________________________

On average how many hours do you work a day? ____________ How many hours a week? ____________

Do you bring your work home with you? YES NO If so, why? ___________________________

How active is your work day? sedentary active Please describe: ____________________________

______________________________________________________________________________________________

How would you describe the dynamics at work? ___________________________________________________

______________________________________________________________________________________________

Are there any other external or environmental factors that you feel may be affecting your health?

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________


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C. FAMILY MEDICAL HISTORY

Please indicate which family relatives (mother, father, grandparents, siblings, aunts or uncles) have ever encountered the following health concerns:

Health Concern Family Relative Health Concern Family Relative

Alcoholism Hypertension

Allergies Infertility

Alzheimer's disease Intestinal disease

Arthritis Learning disability

Asthma Mental illness

Cancer (indicate type) Migraine headaches

Diabetes Neurological disorders

Drug addiction Obesity

Eating disorder Osteoporosis

Genetic disorder Stroke

Glaucoma Suicide

Heart disease Other

# of siblings Your birth order

D. MEDICATIONS / SUPPLEMENTS AND OTHER TREATMENTS

Please check any of the following medications that you are taking or have taken in the last 2 years:

antacids appetite suppressants aspirin / tylenol birth control pills

chemotherapy diuretics (water pills) laxatives pain relievers

radiation recreational drugs sleeping pills tranquilizers

Any known allergies or drug sensitivities? ________________________________________________

Number of times on antibiotics in the last 10 years? ____________

Number of times on corticosteroids in the last 10 years oral? ____________ topical? ____________

DRUGS (if more space is needed, please attach a separate sheet)

Listing of Drugs Dosage / Amount Reason for Taking Duration of Use


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VITAMINS, SUPPLEMENTS, HERBAL OR HOMEOPATHIC REMEDIES (if more space is needed, please attach a separate sheet)

Listing of Medications Dosage / Amount Reason for Taking Duration of Use

OTHER TREATMENTS Please comment on other natural / alternative treatments that you have used.

Treatments Past Current Comments / Effectiveness

Acupuncture / Chinese Medicine

Aromatherapy

Art Therapy

Ayurvedic Medicine

Biofeedback

Chiropractic

Colonics

Cranial Sacral Therapy

Energetic Therapies

Herbal Therapies

Homeopathic

Hydrotherapy

Hypnotherapy

Iridology

Magnetic Therapy

Massage Therapy

Music Therapy

Naturopathic Medicine

Osteopathy

Physiotherapy

Polarity Therapy

Reflexology

Reiki

Shiatsu

Other


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E. EXERCISE

Using the scale provided, identify the number of times a week that you engage in the following exercises. Scale: a (never), b (seldom or less than once per week), c (1 - 3 times per week), d (3 - 5 times per week), e (often or more than 5 times per week).

Never <1/wk 1-3/wk 3-5/wk >5/wk

BODY / MIND EXERCISES

Meditation / Prayer / Breathing Exercises a b c d e

Visualizations (or similar) a b c d e

Other _____________________________ a b c d e

STRENGTH BUILDING

Weight Training a b c d e

Martial Arts (or similar) a b c d e

Other _____________________________ a b c d e

CARDIOVASCULAR EXERCISES

High Impact Aerobics / Step a b c d e

Running / Jogging a b c d e

Low Impact Aerobics / Walking a b c d e

Cycling / Rowing / Swimming a b c d e

Other _____________________________ a b c d e

FLEXIBILITY EXERCISES

Yoga / Tai Chi / Qi Gong (or similar) a b c d e

General Stretching / Lengthening a b c d e

Other _____________________________ a b c d e

How active is your day? ____________________________________________________________

On average, how many hours do you exercise per week? ____________

Do you belong to a gym? YES NO If so, how often do you go? _______________________

Do you prefer to exercise alone? with others? as part of a class?

What benefits have you found from exercising? ___________________________________________

______________________________________________________________________________

Choose the statement that describes you best:

I exercise because I have to (someone has advised an exercise program)

I exercise because I want to exercise for my own health and wellness.

I exercise because I enjoy exercising.


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F. PAST AND PRESENT HEALTH CONCERNS

Did you have any health problems at birth? _______________________________________________________

How was your health as a child? ________________________________________________________________

Describe your health during puberty / teenage years: _______________________________________________

______________________________________________________________________________________________

Please list any injuries, hospitalizations, accidents or medical procedures that you have had: (if required, attach a separate sheet)

Event When? Treatments?

Have you been diagnosed with any illnesses? Explain _____________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

What are your current health concerns? __________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

When did you notice any changes to your health? _________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

What have been the most traumatic events in your life? ____________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________


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G. REVIEW OF PHYSICAL SYMPTOMS

ENERGY LEVEL

On a scale of 1 (low) to 10 (high) rate your energy level? ___________________________________________

What time of the day is your energy the highest? __________________________________________________

What time of the day is your energy the lowest? ___________________________________________________

What affects your energy? ______________________________________________________________________

SLEEP

How is your sleep? ____________________________________________________________________________

Do you ever suffer from insomnia? ________________________ How often? _______________________

How many hours a day do you sleep? ______________________ Do you nap? ______________________

Are you a restful and sound sleeper? If not, please explain. _________________________________________

_____________________________________________________________________________________________

Do you wake feeling rested? ____________________________________________________________________

Do you have frequent dreams and nightmares? ____________________________________________________

BREATHING

How would you describe your breathing? _________________________________________________________

Do you have shortness of breath on exertion? _____________________________________________________

What affects your breathing? ___________________________________________________________________

BODY TEMPERATURE

What is your normal body temperature? _________________________________________________________

Do you like to be warm or cool? ________________________________________________________________

Do you become overly hot or cold throughout the day? ____________________________________________

WEATHER

Are you affected by the weather? _________________________________________________________________

What is favourite type of weather? _______________________________________________________________

What is your least favourite type of weather? ______________________________________________________


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GENERAL SIGNS and SYMPTOMS

Past Concern?

Current Intensity

1 2 3 4 low high

Length of Time

(years) Comments

fever

rapid weight loss

rapid weight gain

overweight

underweight

sensitive to noise

sensitive to light

sensitive to odours

other sensitivities

Height? ____________ inches centimetres Weight? ____________ lbs kg

What do you think would be an acceptable body weight for you? ____________ lbs kg

HEAD and MOUTH Past

Concern?

Current Intensity

1 2 3 4 low high

Length of Time

(years) Comments

dizziness/vertigo

headaches

migraines

frequent sore throats

hoarseness

dry mouth

sore tongue/mouth

cold sores/herpes

gum problems

bad breath

swollen glands

lumps/goitre

nose bleeds

loss of smell

other concerns

Number of dental cavities? ____________ Number of amalgams (silver fillings)? ____________

Last dental check up? ___________ Do you floss? ___________ Do you brush regularly? ___________

Have you had any extensive dental work? YES NO If so, please indicate:

cosmetic dentistry oral surgery orthodontics periodontal therapy other __________


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EYES and EARS Past

Concern?

Current Intensity

1 2 3 4 low high

Length of Time

(years) Comments

near sighted

far sighted

blurred vision

dry eyes

tearing

itchy eyes

eye pain

redness in eyes

eye discharge

dark circles under eyes

bothered by the sun

eye infections

glaucoma/cataracts

diminished hearing

ear aches

ear infections

ringing in ears (tinnitus)

other eye/ear concerns

Date of last eye exam? ___________ Any eye procedures? ___________ Any hearing aids? __________

RESPIRATORY SYSTEM

Past Concern?

Current Intensity

1 2 3 4 low high

Length of Time

(years) Comments

cough

sputum/mucous

sinus congestion

spitting up blood

wheezing

shortness of breath

difficulty breathing

tonsillitis

asthma

bronchitis

pneumonia

tuberculosis

other

Date of last chest x-ray? ____________


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SKIN Past

Concern?

Current Intensity

1 2 3 4 low high

Length of Time

(years)

Comments

dry/cracked skin

moist/oily skin

rashes

eczema

psoriasis

dry scalp/dandruff

hair thinning/loss

acne/boils

itching

colour changes

pale complexion

changes in moles

warts

lumps/cysts

stretch marks

excess body odour

excessive sweating

jaundice

skin cancer

other skin concerns

NERVOUS SYSTEM Past

Concern?

Current Intensity

1 2 3 4 low high

Length of Time

(years)

Comments

fainting

loss of balance

tingling

involuntary movements/twitches

confusion

speech problems

memory problems

seizures/convulsions

paralysis

other


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VASCULAR SYSTEM Past

Concern?

Current Intensity

1 2 3 4 low high

Length of Time

(years)

Comments

hot hands/feet

cold hands/feet

deep leg pain

leg cramps

high blood pressure

low blood pressure

chest pain

slow heart beat

fast heart beat

palpitations

cyanosis (blue skin)

extremity swelling

extremity numbness

varicose veins

easy bleeding/bruising

extremity ulcers

anaemia

heart murmurs

other

Have you ever had a heart stress test? ________

MUSCLES and BONES Past

Concern?

Current Intensity

1 2 3 4 low high

Length of Time

(years)

Comments

broken bones

painful joints

swollen joints

lack of joint mobility

muscle strain/sprain

muscle spasms

prolonged stiffness

heavy feeling in limbs

muscle weakness

muscle atrophy (deterioration)

low back pain

weak/sore knees

arthritis


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Have you had any falls or injuries? YES NO If yes, describe: ______________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

How would you describe your posture? _______________________________________________________________

Is there anything that affects your posture on an ongoing basis? __________________________________________

How would you describe your flexibility? _________________________________________________________

Do you have issues with the range of motion of any of your joints? YES NO If yes, describe:

_____________________________________________________________________________________________

Date of last bone scan? _______________ Results? ___________________________________________________

Please mark an ‘x’ to indicate areas where you feel pain, swelling or discomfort.


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DIGESTIVE SYSTEM Past

Concern?

Current Intensity

1 2 3 4 low high

Length of Time

(years) Comments

change in appetite

change in thirst

change in taste

trouble swallowing

bitter taste

nausea

vomiting

gas or belching

abdominal bloating

heartburn/reflux

indigestion

constipation

diarrhea

hemorrhoids

undigested food in stool

blood in stool

other

BOWEL MOVEMENTS

On average how many bowel movements do you have a day? ________________________________________

Do you strain to have a bowel movement? ____________ What colour are your stools? ____________

Describe the consistency / size of your bowel movements? __________________________________________

APPETITE

Describe your appetite: ________________________________________________________________________

Describe your digestion: _______________________________________________________________________

What makes your digestion worse? ______________________________________________________________

What happens if you skip a meal? _______________________________________________________________

What type of foods do you prefer? salty sweet spicy bitter sour

What temperature of food do you prefer? ________________________________________________________

Any food allergies or intolerances? _______________________________________________________________


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THIRST

Describe your thirst: ___________________________________________________________________________

What temperature of drinks do you prefer? _______________________________________________________

What do you prefer to drink? ___________________________________________________________________

How much water do you drink in a day? _________________________________________________________

What type of water you drink? __________________________________________________________________

URINARY SYSTEM Past

Concern?

Current Intensity

1 2 3 4 low high

Length of Time

(years)

Comments

urinary pain/burning

difficult urination

increased frequency

urgency/inability to hold urine

frequent infections

blood in urine

kidney stones

other

Number of times a day you urinate? _______ Number of times you get up at night to urinate? _______

Is there any odour to your urine? YES NO If yes, please describe _________________________

MALE REPRODUCTIVE SYSTEM

Past Concern?

Current Intensity

1 2 3 4 low high

Length of Time

(years)

Comments

hernias

testicular masses

testicular pain

sexual difficulties

premature ejaculation

discharge or sores

prostatitis

venereal disease

Are you currently sexually active? YES NO Sexual preference? __________________________

What is your sexual desire (rate on a scale of 1 (low) to 10 (high))? __________________________________


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FEMALE REPRODUCTIVE SYSTEM

Past Concern?

Current Intensity

1 2 3 4 low high

Length of Time

(years)

Comments

bleeding between periods

discharge between periods

pain during intercourse

PMS

breast discomfort /changes

fluid retention

hot flashes

night sweats

frequent fungal/ yeast infections

Age menses began: _________ Days flow lasts: __________ Days between periods: __________

Describe your flow: ________________________ When is it the heaviest? ________________________

What is the flow like (clots, colour)? ____________________________________________________________

What symptoms are associated with your period? __________________________________________________

Any pain with your menses? YES NO If so, when is it the worse? ______________________

Are you practising birth control? YES NO If so, what type and since when? ____________

Number of pregnancies: ________________________ Number of live births: _____________________

Number of miscarriages: ________________________ Number of abortions: _____________________

Any problems conceiving? YES NO If yes, explain: __________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Have you done any fertility treatments? YES NO If yes, explain: _______________________

______________________________________________________________________________________________

Are you currently sexually active? YES NO Sexual preference? _________________________

What is your sexual desire (rate on a scale of 1 (low) to 10 (high))? __________________________________

Have you ever been diagnosed with a venereal disease? YES NO If yes, what type? ________

Date of last PAP? _________________________ Last menstrual period? _________________________

Any menopausal symptoms? YES NO If yes, describe: ________________________________

______________________________________________________________________________________________


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EMOTIONAL/ INTELLECTUAL CONCERNS

Past Concern?

Current Intensity

1 2 3 4 low high

Length of Time

(years)

Comments

no free time

mood swings

overly emotional

fears/phobias

depressed

inability to let things go

jealousy

cry often

anger

irritable

hyperactive

grief

worry

nervousness

anxiety

anxiety about exams/ public speaking

burnout

feeling out of control

lack of concentration

learning disability

Do you have an active mind? YES NO Describe your mind chatter: _____________________

______________________________________________________________________________________________

What kinds of tools have been helpful to you on a mental/emotional level? ___________________________

______________________________________________________________________________________________

Do you have a support network? YES NO Please elaborate: ____________________________

______________________________________________________________________________________________


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H. GENERAL INFORMATION ON DIET

On a scale of 1 - 10 (low - high) how would you rate your diet? _____________________________________

Why? _______________________________________________________________________________________

Is there anything about your diet you would like to change? _________________________________________

______________________________________________________________________________________________

On average how many meals do you eat a day? 1 2 3 4 5 +5

Breakfast Lunch Dinner

How much time do your spend preparing?

How much time you spend eating?

Are there any foods that you crave? ________________________ Avoid? _________________________

Do you follow any specific diet regime? vegetarian vegan other __________________________

Do you usually eat alone? with others?

Do you pay attention to the quality of the food that you eat? YES NO

Are you aware of any differences in how you feel with different foods? YES NO

What percentage of your diet is proteins? _________ carbohydrates? _________ fruit? _________

vegetables? _________ other? _________

Do you monitor your intake of fat? salt? fibre? sugar?

Do you add SALT to most meals? YES NO

Do you eat according to the season? YES NO

Do you enjoy food? YES NO

Do you enjoy preparing food? YES NO

Do you look forward to meal time / eating? YES NO

Which statement describes you best?

I look for quick, convenient food choices when grocery shopping and making meals.

I like to eat natural, whole and fresh food whenever I can.

Someone else is usually responsible for what I eat.

I eat out whenever I can.


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Using the scale provided, identify the number of times a week that you engage in the following exercises. Scale: a (never), b (seldom or less than once per week), c (1 - 3 times per week), d (3 - 5 times per week), e (often or more than 5 times per week). Never <1/wk 1-3/wk 3-7/wk >7/wk FRUITS

citrus (oranges, grapefruit, pineapple) a b c d e

berries (strawberries, blueberries) a b c d e

plums, peaches, nectarines, mangoes a b c d e

grapes, melons (cantaloupe, watermelon) a b c d e

apples, pears a b c d e

bananas a b c d e

other fruits a b c d e

Please specify

What percentage of the fruit you eat is raw?

VEGETABLES

root veg (potatoes, carrots, beets, yams) a b c d e

vine veg (tomatoes, cucumbers, zucchini) a b c d e

broccoli, cauliflower, cabbage a b c d e

greens (lettuce, swiss chard, spinach) a b c d e

pickles (all types) a b c d e

other fruits a b c d e

Please specify What percentage of the vegetables you eat is raw?

PROTEIN SOURCES / MEAT

nuts / seeds a b c d e

legumes / beans a b c d e

fish / seafood a b c d e

fowl (chicken, duck, turkey) a b c d e

red (beef, pork, lamb) a b c d e

luncheon meats / processed meat a b c d e

other meats a b c d e

Please specify

MILK PRODUCTS

soya milk / almond milk/ rice milk a b c d e goat or sheep milk / cheese a b c d e

cow’s milk (1%, 2%, skim) a b c d e cheese / yogurt a b c d e ice cream a b c d e other milk products a b c d e

Please specify


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Never <1/wk 1-3/wk 3-7/wk >7/wk GRAINS

millet / kamut / quinoa / barley a b c d e

rye / spelt / pumpernickel a b c d e

multi grain / wild rice a b c d e

whole wheat / brown rice a b c d e

white / processed bread / white rice a b c d e

other grains a b c d e

Please specify

OILS

butter a b c d e

margarine a b c d e

olive oil / flax seed oil a b c d e

canola oil a b c d e

seed oil (sunflower, safflower, almond) a b c d e

vegetable oil a b c d e

other oils

Please specify

HERBS / SPICES

salt a b c d e

pepper a b c d e

garlic, onions, ginger a b c d e

thyme, basil, oregano, sage a b c d e

curry, turmeric, cardamom a b c d e

other spices a b c d e

Please specify

Do you use herbs and spices that are mostly dried? fresh?

CONDIMENTS

ketchup, salsa a b c d e

mustard a b c d e

salad dressings (store bought) a b c d e

mayonnaise a b c d e

other condiments a b c d e

Please specify

SWEETS / SWEETENERS

white / brown sugar a b c d e

honey, agave a b c d e

artificial sweeteners (aspartame, sweet’n’low) a b c d e

candy a b c d e

chocolate a b c d e

other sweets a b c d e

Please specify


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Never <1/wk 1-3/wk 3-7/wk >7/wk BEVERAGES

Coffee a b c d e Tea a b c d e Herbal tea a b c d e Tap / Filtered water a b c d e Bottled / Spring water a b c d e Soft drinks (diet) a b c d e Soft drinks (regular) a b c d e Fruit / Vegetable juices (store bought) a b c d e Fruit / Vegetable juices (fresh) a b c d e Beer a b c d e Wine a b c d e Other alcoholic beverages a b c d e Other a b c d e

Please specify

OTHER FOOD CONSIDERATIONS

Fried foods a b c d e Refined / Processed food (packaged) a b c d e

Micro-waved a b c d e Use of aluminium pans a b c d e Fast foods a b c d e

Eat watching television a b c d e Eat on the run a b c d e Eat in a quite, peaceful atmosphere a b c d e

Chew food at least twenty times a b c d e Relax after eating a b c d e Other

Please specify

Please describe an average:

Breakfast: ___________________________________________________________________________________

Lunch: _____________________________________________________________________________________

Dinner: _____________________________________________________________________________________

Please list any other diet considerations that have not been included above: ____________________________

______________________________________________________________________________________________

______________________________________________________________________________________________


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I. PERSONAL VALUES

Check off all of the following values that are important to you.

Accomplishments / Results

Achievement

Adventure / Excitement

Aesthetics / Beauty

Aloneness

Altruism

Autonomy

Clarity

Commitment

Completion

Connecting / Bonding

Creativity

Environment

Emotional Health

Forward Action

Freedom

Honesty

Fun

Humour

Integrity

Intimacy

Joy

Leadership

Loyalty

Mastery / Excellence

Orderliness / Accuracy

Nature

Partnership

Openness

Personal Growth / Learning

Power

Privacy / Solitude

Recognition

Risk - taking

Romance / Magic

Security

Self-expression

Sensuality

Service / Contribution

Spirituality

Trust

Vitality

Visionary

Other

List the top six values that you have. (You can add your own values if you would like)

What are your pet peeves? ______________________________________________________________________

______________________________________________________________________________________________

What do you want more of in life? _______________________________________________________________

______________________________________________________________________________________________

What do you want less of in life? ________________________________________________________________

______________________________________________________________________________________________


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J. STRESS

Using the scale provided circle the level of stress that you feel for the following aspects of your life and the duration of this stress.

Category None Low Avg. High Duration (years)

PERSONAL 0 1 2 3

HEALTH 0 1 2 3

FINANCIAL 0 1 2 3

UNFULFILLED EXPECTATIONS 0 1 2 3

RELATIONSHIPS 0 1 2 3

MARRIAGE 0 1 2 3

CAREER 0 1 2 3

FAMILY 0 1 2 3

SPIRITUAL 0 1 2 3

OTHER 0 1 2 3

Please specify ___________________________________________________________________

What steps have you taken to deal with your stress? ________________________________________________

Have you ever engaged in counselling or psychotherapy? YES NO How long? ____________

Do you take vacations regularly? YES NO Date of last vacation: _______________________

Which statement that describes you best?

I am concerned about the level of stress in my life.

I feel I have an average amount of stress compared to most people.

I am not concerned about the stress in my life.

OTHER CONSIDERATIONS

Past Concern?

Current Intensity

1 2 3 4 low high

Length of Time

(years)

Comments

abuse (emotional, physical, sexual)

alcohol / drug abuse

accidents / major falls

change / loss of home

change / loss of job

change / addition to household

serious family illness

death of significant other

other


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K. HEALTH POSITIONING STATEMENTS

Please answer YES (you agree with the comment), MAYBE (you feel the comment is sometimes right and sometimes wrong), NO (you don’t agree with the comment), or NO COMMENT (you do not have an opinion, or do not wish to voice your opinion) to the following questions.

Yes

Maybe

No No

Comment

Everything happens for a reason.

The body can heal itself.

You can make yourself sick based on what you think.

You can make yourself sick based on your emotions.

Routine is the only way to get things accomplished.

I can strongly influence my rate of recovery from an illness or injury.

Physical symptoms are often an indicator to change something in my life.

I experience love for many people and aspects of my life.

I don’t think people should take themselves too seriously.

I can manage my stress.

My body is a mirror of my life.

I believe how I live my life is an important factor in determining my state of health, and I live it in a manner consistent with that belief.

What are your short-term health goals? __________________________________________________________

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What are your long-term health goals? ___________________________________________________________

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Please list any other relevant health / personal information that you feel is missing. ____________________

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Thank you!

LIFESTYLE ASSESSMENT - Naturopathic …...33 The Bridle Trail, Unit 3 Telephone: 905-940-2727...

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Transcript of LIFESTYLE ASSESSMENT - Naturopathic …...33 The Bridle Trail, Unit 3 Telephone: 905-940-2727...